Discontinuity of care is a major concern within the US Health Care System. Through financial incentives and regulations, federal and state policies may affect the number and patternof transitions across levels of care. Multiple transitions of frail, older persons have been associatedwith medical errors, bereaved family reports of information discontinuity, and functional decline. While research studies have documented striking geographic variation in health care utilization, few have documented the variation in health care transitions. Merging national Medicare Claims Data and the Minimum Data Set, this research will describe variation in care transitions for four cohorts of older adults: 1) long stay nursing home (NH) residents with moderate to severe cognitive impairment;2) decedents;3) older persons following hip fracture surgery;and 4) persons age 75 and older discharged from an acute care hospital with advanced colorectal cancer. Aim 1 describes patterns and rates of transitions with a focus on geographic variation over a seven year period, 1999 to 2006. Aim 2 examines health system and state factors associated with higher rates of care transitions and complicated, multi-site transitions, and whether changes in state polices are associated with changes in the rate of transitions. Aim 3 examines patient outcomes (e.g. functional decline, bereaved family member perceptions of the quality of end of life care) in geographic regions with varying rates and patterns of care transitions. Aim 4 will be both confirmatory and exploratory;determines whether directors of nursing and NH administrators'attitudes, perceptions, and reports of institutional policies confirm the local practice viz. transition rates. Additionally, this aim willl explore how state policies effect transitions. Knowledge from this research will guide public policy regarding care transitions and improved coordination of care for frail, older Americans. Lay Summary: Frail, older persons often experience changes in settings of health care (i.e., a health care transition). This research will examine how the rates and type of health care transitions vary across the US and how state policies and characterisitics of the local health care market affect such transitions.